Tuesday, November 23, 2010

Cartoons Help Children With Trauma (NYT)

I am really intrigued with this program using cartoons to help children express their feelings when they are unlikely to open up to an adult. At the end of the article Borbolla expresses her desire to take the program to places like Haiti after natural disasters.

The main problem in the developing world is that there are far too few therapists to care for the vast numbers of children who are affected by disaster.

A Safe Haven in Cartoon Confidantes

For months, psychologists struggled to reach the eight year old boy in the burn unit of the Pediatric Hospital of Tacubaya, in Mexico City. He had been discovered in the basement of a house, tied to a water tank after being burned along the backs of both legs with a clothes iron by his uncle and aunt, who were later arrested. Every time an adult tried to talk about his abuse, the boy would turn away and repeat, “No, no, no, no.” One day, a therapist said to a colleague, “Nothing is working. Let’s try Dulas.”

Dulas is a computer-generated character created by Julia Borbolla, a Mexican child psychologist. It is one of several “emotional agents” Borbolla has invented that are being recognized in Mexico City as capable of gaining rare access into the inner lives of children. Dulas, like all of these characters, comes from a planet called Antenopolis and knows nothing about life on earth, not even what a mother or father is. He looks like a pointy-headed M&M with big eyes and radio antennas. He is red, the color children associate with burns, and wears bunny rabbit slippers because he remains in a hospital – so children can count on his companionship.

A therapist named Rafael Mateos Ortiz took the boy to Dulas’s room, which was decorated with stars, planets and children’s art. In the corner a TV screen was set inside a cutout of a 1950s-style spaceship, with mailbox slots for children to place notes or drawings. Mateos explained to the boy that Dulas doesn’t like to interact with adults – so he would only come out after he left the room. Mateos went to an adjacent room and Dulas appeared on the screen. Speaking through Dulas in a software-altered cartoony voice, Mateos used keyboard strokes to make him move and express emotions.

Talking about abuse to Dulas, instead of an adult, has been therapeutic for some traumatized children.

When I visited Mateos recently at the Tacubaya hospital, he told me that, within 30 minutes: “[The boy] told Dulas that he was living in a shelter, that his parents had died, that he had been abused, that he had been burned by his uncle and aunt.” Mateos added: “It was a major step – beginning to talk about his feelings.” Now the therapists had insights they could work with and the boy said he wanted to speak with Dulas again.

Over the past five years, Borbolla’s characters have been used to assist 2,000 children from 3 to 14 years old, and have been employed in three Mexico City hospitals and a center for disabilities in another city, Morelia. The characters collectively go by the name Antenas because they all have antennas and come from Antenopolis (Borbolla’s original character also goes by the name Antenas.). The psychologists I spoke with said the tool creates an environment of trust and empathy that enables them to understand children’s issues more quickly than they imagined possible, and enhances the effectiveness of their work by providing a context in which children find it easier to discover and express their feelings — which carries over to therapy. “In my practice, if I needed four or five visits with a child to understand what really happened — with Antenas I need 10 or 15 minutes, maybe two sessions,” said Borbolla.

Therapists have been using puppets to help children unearth and process their feelings for decades. But Borbolla, who has been working with children for 30 years, has taken this kind of work a step further, assembling elements that haven’t been put together before. To begin with, the children interact with the characters (or cyber-puppets) in a room without adults present (therapists monitor with cameras). The characters also have attributes and stories that are both designed to build rapport and make it easy for children to project their feelings upon them. Because they come from a planet that is different from Earth (but may have similar aspects), they are able to credibly ask naïve questions, like “What is a family?” or “What is a school?” that can elicit revealing answers. Like many children, they prefer not to interact with adults. “Children are drawn to that kind of complicity,” comments Borbolla.

Perhaps most important, therapists must undergo several months of training and practice, under observation, before they can use the tool. Not all therapists receive certification, Borbolla says. It takes a good ear and a light touch ─ playful, enthusiastic, funny at times, but not too funny ─ to understand how to follow the child’s lead and make the characters come alive in a way that respects the child’s feelings and is believable enough to work.

Borbolla originally got the idea to use a drawing of an animated character to communicate with children when she was working as a school psychologist in the 1980s. Years later, in private practice, she worked with a cyber-puppet maker to develop a software version. She spent six years refining the tool. “This is the fruit of many years’ experience and many adjustments,” she told me.

In 2005, she established a nonprofit foundation, Antenas Por Los Ninos, supported by grants, to disseminate the work. The impetus was a comment made by her daughter Juli, who is now 27 and is also a clinical psychologist. Juli had been born without a right ventricle in her heart, and as an infant and child she had undergone repeated surgeries and hospitalizations. Borbolla recalled: “She told me, ‘If I had had Antenas in the hospital, I would have asked the character many things I never asked because I was afraid of saying things that might hurt you or my father. I wanted to know if I was going to die. I wanted to know what else was going to happen to me.’ ”

Antenas characters have been used to assist children who are experiencing a range of difficulties. Therapists in Tacubaya use them in pre- and post-operative therapy and burn rehabilitation. In Morelia, one character, Bompi, is employed to assist children with disabilities. (Bompi says that all humans have disabilities because they don’t have antennas.) The program is being used to provide emotional support to children with heart disease and cancer, teach children how to protect themselves from potential abuse, and, at the government’s request, learn about children’s experiences in public day care centers. In a pilot project being conducted by the Pediatric Hospital of Iztapalapa in conjunction with four government agencies, children’s interactions with another character are carefully being reviewed as potential legal evidence in cases of violence or abuse.

One of the first times Borbolla used the Antenas character was with a five-year-old girl whose parents brought her in because she had been wetting her bed. Antenas asked the girl, “Who do you live with?” She replied: “My father, my mother, my little brother, and the maid.” When Antenas asked: “What’s a maid?” the girl replied “It’s a woman who helps mother with the house and when your father goes out, she hurts you.” Another time Antenas asked a young boy, “What’s a driver?” and the boy said that a driver is a man who uses the car and touches you in the guest bathroom when your parents go out. Borbolla explained that these disclosures ─ spontaneous responses to general questions ─ are highly reliable, especially when they come from young children. But therapists also follow up with the child and the family to confirm facts.

In such cases, therapists have to handle the information carefully. One principle of the work is that a therapist must not reveal that she knows something that was said to an Antenas character privately. The character must first ask permission of children to share any information with a “good adult.” This preserves the trust and integrity of the child’s relationship with the character. In the case of the boy and the driver above, Antenas said he should tell what he said to “Julia, that lady who brought you here.” The boy replied, “If I tell someone the driver will kill my mother.” Antenas said, “She will know how to protect you and your mother.” The boy gave permission for Antenas to tell Julia and she made sure the child’s parents, who happened to be wealthy, came directly to her office to pick up the boy (the driver was waiting for him outside) to deal with the matter.

Over the years, Borbolla has gained insights into children simply by having a character ask basic questions like “What is a mother?” or “What is a father?” With children in hospitals, the character may ask: ‘What is a doctor?’ If the child responds ─ as many do, in effect ─ “A mean person who makes you suffer,” then Antenas can help the child handle his fears and adapt to his treatment.

The psychologists I spoke and emailed with said they loved the tool. Ana Zarina Fiorentini Cañedo, who supervises the psychological program at Tacubaya, wrote that she highly recommends the program for hospitals because of its efficacy in helping children heal from the emotional pain of illness. Some psychologists have concerns about children being deceived into thinking they are confiding with a character when they are in fact talking to human adults. Borbolla acknowledges it, but says that it’s an extension of the established practice of using puppets. And she is careful to add that Antenas is no substitute for therapy. (She likes to limit its use to six sessions.) “It is a simple tool, but it can be enriched with the personality of each expert,” she says.

To date, Antenas hasn’t been rigorously studied, and Borbolla is working to engage researchers to examine its impact. She is developing an Internet-based application to reach children who are immobile. And she dreams of having the resources to bring the tool into disaster areas, like Haiti. “After an earthquake, everybody thinks of food and blankets, but what are the children feeling? How are they faring?” Her biggest fear is that the tool will be co-opted for negative purposes. “I see how powerful it is,” she told me. “It can be used to get into the souls of children.”

On Saturday, I’ll provide more examples of the Antenas characters’ interactions with children and respond to reader comments about the idea.